Deldar et al.

BMC Nursing (2018) 17:11

https://doi.org/10.1186/s12912-018-0281-3

RESEARCH ARTICLE Open Access

Challenges faced by nurses in using pain

assessment scale in patients unable to
communicate: a qualitative study
Kolsoum Deldar1, Razieh Froutan2* and Abbas Ebadi3

Abstract
Background: One helpful strategy adopted for pain management in non-verbal, intubated patients is the use of a
proper pain assessment scale. The purpose of the present study is to achieve a better and deeper understanding of
the existing nurses’ challenges in using pain assessment scales among patients unable to communicate.
Methods: This qualitative study was conducted using content analysis. Purposive sampling was used to select the
participants and continued until data saturation. The participants included 20 nurses working in intensive care units.
Data was collected using semi-structured interviews and analysis was done using an inductive approach.
Results: Four categories and ten sub-categories were extracted from the experiences of the nurses working in the
intensive care units in terms of nursing challenges in using non-verbal pain assessment scales. The four categories
included “forgotten priority”, “organizational barriers”, “attitudinal barriers”, and “barriers to knowledge”.
Conclusions: The findings of the present study have shown that various factors might influence on the use of non-
verbal pain assessment scales in patients unable to communicate. Identifying these challenges for nurses can help
take effective steps such as empowering nurses in the use of non-verbal pain assessment scales, relieving pain, and
improving the quality of care services.

Background may not be able to accurately estimate the level of their

Pain is an unpleasant sensory and emotional experience
associated with actual or potential tissue damage or
described in terms of such damage [1]. It is a common
phenomenon and a major stressor in intubated patients
[2–4]. Various reasons other than the original disease,
e.g. endotracheal tube suctioning, chest tube insertion,
respiratory exercises, coughs, and certain positions on
the bed, can cause pain [5–7]. Despite advances in the-
ories related to pain control [8–11], pain is still a major
problem in critically ill patients admitted to intensive
care units (ICU) and 40–77.4% of ICU patients complain
about the experience of pain [12, 13]. Since these pa-
tients may suffer from numerous neurological, physio-
logical, and communicative disabilities arising from a
variety of reasons including dependence on a mechanical
ventilator (MV) and concurrent use of sedatives, they
* Correspondence: Froutanr@mums.ac.ir
2
Department of Medical-Surgical Nursing, School of Nursing and Midwifery,
Mashhad University of Medical Sciences, Mashhad, Iran
Full list of author information is available at the end of the article
pain [14, 15]. Inappropriate diagnosis of pain experi-
enced by ICU patients is also associated with complica-
tions such as increased risk of infection, prolonged MV,
hemodynamic disorders, paranoia, immune-suppression,
and even death [16–18].
Some researchers believe that the most reliable
method of pain evaluation is the patient’s self-report
[16]. But if patient doesn’t have enough ability to provide
verbal self-report of pain (e.g. ICU patients), it is recom-
mended to use other available methods for pain manage-
ment [14].
The first step in the management of pain is its diagnosis
and evaluation [19], i.e. a reliable pain assessment tool is
essential to efficient pain management [14, 20–22]. Such a
tool can contribute to correct decision-making during pain
management [23, 24] and promote pain diagnosis and
evaluation [25]. Therefore, an effective pain assessment
scale should be a part of the recording process system.
Since evaluation is a basic principle in nursing care and it
can form the foundation for nursing interventions, each

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Deldar et al. BMC Nursing (2018) 17:11
hospital should have a practical approach to pain measure-
ment [26]. A variety of pain measurement tools, including
the Visual Analogue Scale (VAS), Numeric Rating Scale
(NRS), Verbal Descriptor Scale (VDS), Smiling Face Scale
(SFS), and Numeric Descriptor Scale (NDS), can be used
to determine the severity of pain and its related behaviors
[27–30]. In addition, the Behavioral Pain Scale (BPS),
Critical-Care Pain Observation Tool (CPOT), and Nonver-
bal Pain Scale (NVPS) can be administered to screen pain
in critically ill ICU patients who are unable to communi-
cate [31, 32]. This group of patients may include uncon-
scious, sedated, or intubated patients, as well as those with
reduced consciousness levels, communication barriers, or
head trauma [10, 33]. However, there are few documents
on the use of such scales. According to G’elinas et al.
(2004), pain assessment scales were only employed in 1.6%
of the 183 events recorded for intubated patients. Al-
though evaluation of pain behaviors was common (re-
ported in 73% of cases), such evaluations and observations
were conducted without any valid and reliable tools [34].
In a study on 3601 critically ill intubated patients, Payen et
al. (2007) found that pain was not assessed in 53% of the
patients who had received pain-killers. Moreover, only
28% of pain evaluations were performed through appropri-
ate and specific pain assessment tools [35].
Since all patients under MV receive analgesics or seda-
tives, mostly narcotic drugs, pain assessment scales for
these patients have not received adequate attention [36].
It seems that efficient pain evaluation and management
for critically ill patients has become a major challenge
for ICU nurses [21]. Therefore, considering the role of
nurses as the main individuals involved in pain evalu-
ation and management, this study sought to address the
nurses’ challenges in the use of pain assessment tools in
patients unable to communicate.
Methods
Study design
This qualitative study was conducted using content ana-
lysis. The researchers performed an in-depth direct ana-
lysis of experiences of ICU nurses. The findings are
presented as codes, subcategories, and categories using
an inductive approach [37].
Participants and study setting
The selection of participants was performed using a pur-
poseful sampling method. 20 interviews were conducted
with nurses working in ICUs. Subject selection was con-
ducted with maximum variation in personal factors (age,
education level, duration of work experience, and
organizational role). Data was collected using semi-
structured interviews, and analysis was done using an in-
ductive approach. All study participants were interested
in sharing their experiences.
Page 2 of 8
Ethical considerations
This study was approved by the Ethics Committee of
Mashhad University of Medical Sciences in May 2016
(code: IR.MUMS.REC.1395.159). Moreover, the partici-
pants were ensured of data confidentiality and auton-
omy. They were informed of the purpose of the study
and the voluntary nature of their participation. A written
consent was obtained from all participants before re-
cording the interviews.
Data collection and analysis
Content analysis was performed on Persian transcripts,
before translation. The interviews were started with a
number of general questions (e.g. “Please describe one of
your experiences of one day working in the ICU.”) and
continued with more specific questions (e.g. “Please
speak about your own experiences of pain management
in patients unable to communicate.”, “Please describe
your experiences of using non-verbal pain scales.”, and
“What problems and issues do you face?”). Individual
semi-structured interviews were conducted in a private
room at the participants’ workplace.
Based on the Graneheim and Lundman’s method [37],
the analysis process consisted of the following steps:
1. The recorded interviews were transcribed and read
to get an overall understanding.
2. The texts were divided into meaningful units.
3. The meaningful units were extracted and encoded.
4. Based on their similarities and differences, the initial
codes were classified into subcategories.
During the open coding stage, all the transcripts were
reread closely and thoroughly for several times and the
keywords, expressions, incidents, and actualities were
noted. The basic codes were taken, and the codes and all
extracted data were compared to identify the existing
similarities and differences. Afterward, the categories
and subcategories were created. A preparatory arrange-
ment of codes, categories, and subcategories was framed
from the first interview, and the developing codes were
considered as the outcomes.
Trustworthiness
Maximum variation sampling, member checking, and
peer questioning and cross-examination were used to
ensure the trustworthiness, dependability, and credibility
of the data, respectively. In order for member checking,
each participant was provided with the transcript of his/
her coded interview along with a summary of the ex-
tracted themes and asked to determine whether the
codes are representative of and matched with their expe-
riences. Peer checking of the transcripts was conducted
by two faculty members with a PhD in nursing. They
Deldar et al. BMC Nursing (2018) 17:11
received the transcripts and followed the above-
mentioned process to reach the core themes. The ob-
tained inter-rater agreement was equal to or above 90%.
The long presence of the authors in the field (from
May 2016 to Apr 2017) enabled them to win the partici-
pants’ trust and develop strong communication links
with the interviewees. This facilitated precise data
collection.
Results
The study sample consisted of 20 ICU nurses (nine men
and 11 women). The mean age and mean work experi-
ence were 35.7 ± 6.1 and 12.3 ± 6.1 years, respectively.
Other details are available in Table 1.
The factors inhibiting the use of pain assessment
scales in patients unable to communicate were grouped
into four categories including “forgotten priority”,
“organizational barriers”, “attitudinal barriers”, and “bar-
riers to knowledge” (Table 2).
The findings along with their related quotes are shown
below:
Forgotten priority
One of the concepts extracted from data analysis based
on the experiences of our participants was “forgotten
priority”. This category consisted of four subcategories
including: “non-routine pain assessment/evaluation”, “in-
adequate physician-nurse interaction regarding patient
pain”, “absence of non-verbal pain assessment scales in
the nursing flowchart”, and “lack of relevant policies and
clinical guidelines”.
Due to non-routine pain assessment/evaluation in pa-
tients unable to communicate, nurses did not use pain
measurement scales for these patients. As participant #8
stated:
“… I have been working in the ICU for about 7 years…
almost all the duties in our shifts are routine... care for
the airway and attention to the alarms of the
mechanical ventilators... during this time I have not
performed evaluation of pain for patients with
decreased level of consciousness (LOC)... Well, until now,
pain evaluation and recording have not been conducted
routinely for these patients… therefore, there has been
no necessity to use non-verbal pain assessment scales...”
Table 1 Summary of participant characteristics
Variables Status Percent
Gender Females 55%
Males 45%
Educational Degree Bachelor’s 90%
Master’s or higher 10%
Page 3 of 8
Table 2 The main categories and related sub-categories
Category Sub-category
Forgotten Non-routine pain assessment/evaluation
priority
Inadequate physician-nurse interaction in
terms of patient pain
Absence of non-verbal pain assessment scales
in the nursing flowchart
Lack of policies and clinical guidelines
Organizational Inadequate nurse-patient ratio
barriers
Presence of less experienced personnel
Attitudinal Adequacy of sedatives
barriers
Failure to understand pain in unconscious patients
No belief in non-verbal pain assessment scales
Barriers to Unfamiliarity with the use of non-verbal pain
knowledge assessment scales
Insufficient training for clinical use of pain
assessment scales
The second category of “forgotten priority” was in-
adequate physician-nurse interaction regarding patient
pain. Despite the fact that pain management is an im-
portant patient right and a health-care priority, pa-
tient pain is seldom mentioned during the visit time.
Participant #13 mentioned that:
“...during the visits of intubated patients
experiencing decreased LOC; test results, respiratory
mode, and so on are discussed and there are not
talks about patient pain and its evaluation
results… well, this situation can impact the use of
non-verbal pain assessment scales for such
patients...”
Given the absence of non-verbal pain assessment
tools in the nursing flowchart, the nurses believed
that no place (in patient record or nursing flowchart)
was specified for the use of these standardized tools
despite the importance of pain relief in patients under
MV. Participant #20 indicated that:
“... We can record the results of arterial blood
gases, blood tests, vital signs, and nursing reports
in the nursing flowchart… however, no place has
been specified for non-verbal pain assessment
tools…”
Lack of relevant policies and clinical guidelines was
the fourth subcategory obtained from the analysis of
“forgotten priority”. The participating ICU nurses
highlighted the absence of clinical guidelines on the
selection and use of various non-verbal pain assess-
ment tools. Participant #17 stated that:
Deldar et al. BMC Nursing (2018) 17:11
“… It is definitely important to me to relieve
pain in patients who cannot self-report it...
however, the hospital has never introduced a
standardized scale to us even though there are
various scales in this context to help the personnel
to act in the same manner, but not based on their
tastes.”
Organizational barriers
The participants underscored “organizational barriers”
as other challenges faced by ICU nurses. This cat-
egory contains two subcategories including “inad-
equate nurse-to-patient ratio” and “presence of less
experienced personnel”.
The participants argued that heavy workload and
time limitations, consequent to inadequate nurse-to-
patient ratio, prevented them from providing constant
high-quality care. Participant #12 indicated that:
“Due to the high workload in the ICU, being
responsible for two or more patients admitted into the
ICU in each shift, health information system
recordings, and paperwork; there is no possibility to
use non-verbal pain assessment scales.”
Analyzing the viewpoints of less experienced nurses
(newly employed) showed that their attention and en-
ergy was mainly focused on acquiring skills such as
working with ICU equipment, doing procedures, and
calculating drug dosage. They, hence, had no opportun-
ity to work with non-verbal pain assessment scales.
Therefore, the “presence of less experienced personnel”
served as another organizational barrier. Participant #9
said that:
“... My incentives in the ICU are to learn about the
mechanical ventilators… I significantly focus on the
calculation and regulation of infusion of medicines,
the alarms of mechanical ventilators,…”
Attitudinal barriers
“Attitudinal barriers” in nurses was another concept
derived from data analysis. This category consisted of
three subcategories including “adequacy of sedatives”,
“failure to understand pain in unconscious patients”,
and “no belief in non-verbal pain assessment scales”.
Nurses are responsible for pain assessment and
should adopt pain-reducing procedures if pain is not
relieved. However, the participating nurses believed
that there was no need to use pain assessment scales
when a patient received sedative infusions. Participant
#7 argued that:
Page 4 of 8
“…there is no need to use pain assessment scales for
patients with decreased LOC when drugs such as
fentanyl are used in the form of infusion… because
they are taking sedatives…”
Moreover, the subcategory “failure to understand pain
in unconscious patients” was extracted from the partici-
pants’ statements indicating that patients with decreased
LOC could not feel pain. Participant #2 reiterated that:
“…patients with impaired consciousness have no pain...
in fact; they do not feel pain... so it is not necessary to
use pain assessment scales for such patients...”
The participants believed that non-verbal scales could
not measure and evaluate pain correctly. They, thus, had
“no belief in non-verbal pain assessment scales”. They
considered their personal judgments of patient pain as
the best pain assessment method. Participant #5 dis-
cussed that:
“... Lots of these pain scales are out of use… they are
not 100% correct... I feel that I can evaluate and assess
pain… an example is the scale developed for
embolism… we had cases in which negative embolism
was reported using these scales, but the patient was
affected with embolism clinically...”
Barriers to knowledge
Another category extracted from data analysis was “bar-
riers to knowledge”. This category contained two sub-
categories including “unfamiliarity with the use of non-
verbal pain assessment scales” and “insufficient training
on the clinical use of pain assessment scales”.
Based on the participants’ statements, undergraduate
education did not provide nursing students with ad-
equate knowledge on pain assessment. Therefore, un-
familiarity with pain assessment accounted as a major
barrier to pain assessment and measurement. Most par-
ticipating nurses stated that they had not received ad-
equate training on pain assessment and measurement
scales in either school or workplace (hospital). Partici-
pant #13 said that:
“.. well, it is natural that we are kind of familiar with
these standardized pain assessment scales... because my
colleagues and I, who are working in the ICU, hold
undergraduate degrees... well, pain assessment scales are
not very often included in the undergraduate programs.”
Participant #7 highlighted “insufficient training for the
clinical use of pain assessment and measurement scales”
and argued that:
Deldar et al. BMC Nursing (2018) 17:11
“…we have never taken certified training classes
in the hospital to become familiar with pain
assessment scales as well as the necessity to employ
them for patients in the ICU and for those connected
to the mechanical ventilator up until now… there
have been just sporadic classes in
this unit…”
Discussion
Four main categories, including “forgotten priority”,
“organizational barriers”, “attitudinal barriers”, and
“barriers to knowledge” were extracted from the analysis
of the experiences of ICU nurses. Specific subcategories
of each category were also determined based on unique
and integrated properties. This study was among the
first Iranian studies to adopt a qualitative approach to
explore the experiences of ICU nurses about the use of
pain assessment scales. It sought to answer the question:
“What challenges are experienced by ICU nurses when
using pain assessment tools in patients unable to
communicate?”
The findings of this study indicated that although ICU
nurses perform routine practices for patients unable to
communicate during each shift; they do not follow a
routine pain management protocol in this group of pa-
tients. Nevertheless, pain management is a major deter-
minant of nursing care quality, i.e. pain should be
evaluated when vital signs are measured and its relief
should be considered as the core and essence of nursing
care [38]. Nurses are also responsible for the prevention
or reduction of pain [39]. They are, in fact, one of the
important healthcare team members with proper oppor-
tunities to assess, identify, and evaluate pain manage-
ment. They are, hence, required to play an active role in
pain management. However, few studies have shown that
nurses are actually playing such roles [40].
While nurses’ efforts for pain management mainly aim
to improve patient outcomes, there is no appropriate
non-verbal pain assessment scale to evaluate pain in
ICU patients. It seems that failure in this respect can
lead to decreased quality of pain management in patients
unable to communicate. According to Bucknall et al.
(2007), nurses can only make effective decisions for pain
management through the repeated and regular evalu-
ation of pain intensity and related behaviors [41]. Erdek
et al. (2004) concluded that there was not an appropriate
form of pain assessment in ICU patients and such pa-
tients were unable to self-report their pain [42]. A study
in Jordan reported that the existing pain assessment
methods applied in the ICUs of the country only focused
on pain management among patients suffering from
cancer. In fact, no particular pain assessment tools were
used for ICU patients who are unable to communicate
Page 5 of 8
[43]. Similar barriers were reported by ICU nurses in the
United States [42].
The experiences of the ICU nurses in this study indi-
cated that physicians’ inattention to pain monitoring, de-
creased nurse’s attention to pain and its relief. Our
participants reported physicians focused on several com-
plications, such as fever, but failed to evaluate pain.
Nevertheless, pain relief is an essential human right and
a major nursing priority [44].
The absence of non-verbal pain assessment scales in
nursing flowcharts is another challenge which ICU
nurse’s face while adopting pain management strategies.
Currently, the nursing flowchart in these units only uses
VAS and SFS to record patient pain. However, there is a
need for a standardized form of non-verbal pain assess-
ment and measurement for patients unable to communi-
cate. In the absence of such scales, as well as a specific
system for the analysis of their results, the effectiveness
of treatments cannot be accurately determined [10].
However, the inclusion of the pain management section
in the ICU checklist, as a part of daily activities, can be
considered as a valuable scale for reducing patient dis-
comfort [45].
The ICU nurses participating in this study used infu-
sions of sedatives and narcotic drugs for patients unable
to communicate without following any pain assessment
scales and specific guidelines. Lack of relevant policies
and guidelines on pain control was also reported by
Keykha et al. (2013) [46]. Nevertheless, lack of access to
clinical pain management guidelines can negatively
affect pain management [29, 47], i.e. the use of guide-
lines and non-verbal pain assessment scales would have
positive effects on the experience of pain reduction in
ICU patients.
Based on the findings of the present study, the un-
desirable nurse-to-patient ratio in the ICUs and nurses’
heavy workload forced nurses to disregard some clinical
practices and prevented them from the frequent use of
pain assessment tools. The time limits could also inter-
fere with the quality of care and were thus considered as
a barrier to optimal care [48]. On the other hand, limited
time forced nurses to prioritize duties of equal import-
ance [49]. Unfortunately, the alarming shortage of nurses
is considered as an important challenge in healthcare
systems [50, 51]. In Iran, there is a need for over100
thousand more nurses [52].
Apart from the issue of time, experiences and skills of
the nurses are similarly critical in pain diagnosis [53].
The less experienced ICU nurses recruited in this study
had no opportunities for performing pain measurement
and working with non-verbal pain assessment tools be-
cause they were mostly interested in the acquisition of
other skills (e.g. working with the MV and other
equipment).
Deldar et al. BMC Nursing (2018) 17:11
The findings of this study highlighted the viewpoints
of ICU personnel’s as other factors influencing the use
of pain assessment scales. In fact, pain management
often depends on the viewpoints, culture, and beliefs of
the health-care team [54]. The ICU nurses in this study
believed that there was no need to use pain assessment
scales for patients receiving sedatives. Examining their
viewpoints and experiences also revealed that the
personnel did not feel any need to assess pain in
patients when they were receiving pain-killers and seda-
tives prior to performing invasive and painful proce-
dures. The findings of a study in this respect also
showed that most patients under an MV received seda-
tives and pain-killers without any particular pain as-
sessment [35]. However, prescribing the correct dosage
of sedatives in patients with decreased LOC requires
the routine administration of pain assessment tools
[55]. Enskar et al. (2007) showed that Swedish nurses
had more knowledge about pain assessment and more
positive attitudes towards pain. These factors could lead
to better pain relief [56].
“Failure to understand pain in unconscious patients”
was another concept derived from the experiences of
the ICU personnel in this study. The nurses argued that
patients with decreased LOC had no pains, i.e. pain as-
sessment and scales were not necessary for these pa-
tients. Likewise, nurses in other investigations mainly
neglected pain in unconscious patients. They did not
actually consider pain as a serious issue since they as-
sumed that patients with decreased LOC did not have a
sense of pain [57]. However, the point of importance is
that the state of sleep and sedation is not equal to the
absence of pain or its relief [14]. It is difficult to evalu-
ate pain in such patients due to the inability to commu-
nicate following decreased LOC, receiving sedatives,
and using the MV. Consequently, inadequate pain man-
agement and control in unconscious patients has been
raised as a challenge in nursing care [58].
The final concept obtained from this category of ex-
periences by ICU nurses was “no belief in pain manage-
ment scales”. The nurses did not believe in pain scales
and argued that personal judgment of the patient’s pain
was the best method of pain assessment because they
had experiences of ineffective use of other tools such as
the scale for embolism. Given their high workload and
time limits, these nurses also believed that they could
assess patients’ pain only through the patient’s face and
observation of their hemodynamics. Other studies have
also mentioned personal beliefs and viewpoints as
major barriers in this respect. The personnel’s lack of
belief can thus lead to treating patients based on their
personal opinions [59]. Given that nurses need tools to
correctly assess pain [39, 60], they should avoid per-
sonal assessment and judgment in this respect.
Page 6 of 8
The concept of “barriers to knowledge” indicates that
“unfamiliarity with non-verbal pain assessment scales”
and “inadequate ability to use non-verbal pain assess-
ment scales” are among the main challenges in this do-
main. In the present study, the ICU nurses did not use
pain measurement scales because they received little in-
formation in their undergraduate programs or in-service
re-training courses about pain assessment scales. Most
nurses believed that they were not well prepared for this
function during their training courses presented in nurs-
ing education centers [61].
Moreover, Rose et al. (2012) examined the perform-
ance of ICU nurses regarding pain management and
control. They reported that nurses were not willing to
use pain assessment scales in non-verbal patients and
that they had little information about such scales, which
could negatively affect their performance in terms of pa-
tient pain management [62].
In this regard, Farahani et al. (2008) stated that inad-
equacy of training courses for pain measurement was
one of the significant barriers to its use [63]. Therefore,
training pain assessment scales, their use and the related
guidelines are of utmost importance for improving sys-
tematic pain assessment in ICU patients and ultimately
for increasing nurses’ knowledge of pain care.
Conclusion
The findings of the present study indicate that various
factors such as “forgotten priority”, “organizational bar-
riers”, “attitudinal barriers”, and “barriers to knowledge”
could affect the use of scales for pain assessment and
management in patients unable to communicate. Given
the inability to self-report in these patients, pain cannot
be properly assessed and treated in such patients. The
existing barriers to using non-verbal pain assessment
scales in these patients can also lead to false evaluations
of pain by nurses and consequently unrealistic percep-
tion of pain and inadequate medication. Identifying these
challenges for nurses can help take effective steps such
as empowering nurses in the use of non-verbal pain as-
sessment scales, relieving pain, and improving the qual-
ity of care services.
Abbreviations
ICU: Intensive care unit; LOC: Decreased level of consciousness;
MV: Mechanical ventilator
Acknowledgements
We are grateful to Research deputy of Mashhad University of Medical
Sciences for great cooperation on this research. Also we would like to thank
all the ICU nurses who participated in our study and gave up their valuable
time to be interviewed.
Availability of data and materials
The datasets generated and analyzed during the current study are not
publicly available due to the request of participants about their
confidentiality, but are available from the corresponding author on
reasonable request.
Deldar et al. BMC Nursing (2018) 17:11
Funding
No funding.
Authors’ contributions
RF led the study; RF, KD and AE contributed to the design of the study; RF
and AE analyzed the data; all authors interpreted the findings; RF and KD
compiled the first draft of the paper; all authors commented on drafts of the
paper and approved the final draft of the paper.
Ethics approval and consent to participate
This study was approved by the Ethics Committee of Mashhad University of
Medical Sciences in May 2016 (code: IR.MUMS.REC.1395.159). A written
consent was obtained from all participants before recording the interviews.
They were informed of the purpose of the study and the voluntary nature of
their participation.
Consent for publication
The article does not contain any individual’s details and consent for
publication is not applicable.
Competing interests
The authors declare that they have no competing interests.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Department of Medical Informatics, Faculty of Medicine, Mashhad University
of Medical Sciences, Mashhad, Iran. 2Department of Medical-Surgical Nursing,
School of Nursing and Midwifery, Mashhad University of Medical Sciences,
Mashhad, Iran. 3Behavioral Sciences Research Center, Faculty of Nursing,
Baqiyatallah University of Medical Sciences, Tehran, Iran.
Received: 30 November 2017 Accepted: 8 March 2018
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